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El. knyga: Drift into Failure: From Hunting Broken Components to Understanding Complex Systems

4.01/5 (332 ratings by Goodreads)
(Griffith University, Nathan Campus, Australia)
  • Formatas: 234 pages
  • Išleidimo metai: 05-Dec-2016
  • Leidėjas: Ashgate Publishing Limited
  • Kalba: eng
  • ISBN-13: 9781351942911
  • Formatas: 234 pages
  • Išleidimo metai: 05-Dec-2016
  • Leidėjas: Ashgate Publishing Limited
  • Kalba: eng
  • ISBN-13: 9781351942911

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What does the collapse of sub-prime lending have in common with a broken jackscrew in an airliner’s tailplane? Or the oil spill disaster in the Gulf of Mexico with the burn-up of Space Shuttle Columbia? These were systems that drifted into failure. While pursuing success in a dynamic, complex environment with limited resources and multiple goal conflicts, a succession of small, everyday decisions eventually produced breakdowns on a massive scale. We have trouble grasping the complexity and normality that gives rise to such large events. We hunt for broken parts, fixable properties, people we can hold accountable. Our analyses of complex system breakdowns remain depressingly linear, depressingly componential - imprisoned in the space of ideas once defined by Newton and Descartes. The growth of complexity in society has outpaced our understanding of how complex systems work and fail. Our technologies have gotten ahead of our theories. We are able to build things - deep-sea oil rigs, jackscrews, collateralized debt obligations - whose properties we understand in isolation. But in competitive, regulated societies, their connections proliferate, their interactions and interdependencies multiply, their complexities mushroom. This book explores complexity theory and systems thinking to understand better how complex systems drift into failure. It studies sensitive dependence on initial conditions, unruly technology, tipping points, diversity - and finds that failure emerges opportunistically, non-randomly, from the very webs of relationships that breed success and that are supposed to protect organizations from disaster. It develops a vocabulary that allows us to harness complexity and find new ways of managing drift.

Recenzijos

'"Accidents come from relationships, not broken parts." Sidney Dekker's meticulously researched and engagingly written Drift into Failure: From Hunting Broken Parts to Understanding Complex Systems explains complex system failures and offers practical recommendations for their investigation and prevention from the combined perspectives of unruly technology, complexity theory, and post-Newtonian analysis. A valuable source book for anyone responsible for, or interested in, organizational safety.' Steven P. Bezman, Aviation safety researcher 'Dekkers book challenges the current prevalent notions about accident causation and system safety. He argues that even now, what profess to be systemic approaches to explaining accidents are still caught within a limited framework of cause and effect thinking, with its origins in the work of Descartes and Newton. Instead, Dekker draws his inspiration from the science of complexity and theorises how seemingly reasonable actions at a local level may promulgate and proliferate in unseen (and unknowable) ways until finally some apparent system "failure" occurs. The book is liberally illustrated with detailed case studies to articulate these ideas. As with all Dekkers books, the text walks a fine line between making a persuasive argument and provoking an argument. Love it or hate it, you cant ignore it.' Don Harris, HFI Solutions Ltd 'Dekker's book contributes to the growing debate around the nature of retrospective investigations of safety-critical situations in complex systems. Both provocative and insightful, the author shines a powerful light on the severe limits of traditional linear approaches. His call for a diversity of voices and narratives, to deepen our understanding of accidents, will be welcomed in healthcare. Dekkers proposal that we shift from going "down and in" to "up and out" suggests a paradigm shift in accident investigation.' Rob Robson, Healthcare System Safety and Accountability, Canad

List of Figures
vii
Acknowledgments ix
Reviews for Drift into Failure x
Preface xi
1 Failure is Always an Option
1(24)
Who messed up here?
1(5)
Technology has developed more quickly than theory
6(5)
Complexity, locality and rationality
11(2)
Complexity and drift into failure
13(5)
A great tide, a lousy metaphor
18(4)
References
22(3)
2 Features of Drift
25(26)
The broken part
31(4)
The outlines of drift
35(11)
A story of drift
46(3)
References
49(2)
3 The Legacy of Newton and Descartes
51(20)
Why did Newton and Descartes have such an impact?
54(4)
So why should we care?
58(7)
We have Newton on a retainer
65(4)
References
69(2)
4 The Search for the Broken Component
71(16)
Broken components after a hailstorm
72(3)
Broken components to explain a broken system
75(1)
Newton and the simplicity of failure
76(10)
References
86(1)
5 Theorizing Drift
87(40)
Man-made disasters
87(6)
High reliability organizations
93(6)
Goal interactions and production pressure
99(4)
Normalizing deviance, structural secrecy and practical drift
103(13)
Control theory and drift
116(5)
Resilience engineering
121(2)
References
123(4)
6 What is Complexity and Systems Thinking?
127(42)
More redundancy and barriers, more complexity
127(3)
Up and out, not down and in
130(3)
Systems thinking
133(5)
Complex systems theory
138(15)
Complexity and drift
153(13)
References
166(3)
7 Managing the Complexity of Drift
169(36)
Complexity, control and influence
169(4)
Diversity as a safety value
173(3)
Turning the five features of drift into levers of influence
176(9)
Drifting into success
185(2)
Complexity, drift, and accountability
187(11)
A post-Newtonian ethic for failure in complex systems
198(4)
References
202(3)
Bibliography 205(6)
Index 211
Sidney Dekker is Professor and Director of the Key Centre for Ethics, Law, Justice and Governance at Griffith University in Brisbane, Australia. Previously Professor at Lund University, Sweden, and Director of the Leonardo Da Vinci Center for Complexity and Systems Thinking there, he gained his Ph.D. in Cognitive Systems Engineering from The Ohio State University, USA. He has worked in New Zealand, the Netherlands and England, been Senior Fellow at Nanyang Technological University in Singapore, Visiting Academic in the Department of Epidemiology and Preventive Medicine, Monash University in Melbourne, and Professor of Community Health Science at the Faculty of Medicine, University of Manitoba in Canada. Sidney is author of several best-selling books on system failure, human error, ethics and governance. He has been flying the Boeing 737NG part-time as airline pilot for the past few years. The OSU Foundation in the United States awards a yearly Sidney Dekker Critical Thinking Award.